Tanzania_SO10_PEPFAR_IEE.pdf

INITIAL ENVIRONMENTAL EXAMINATION

AND

CATEGORICAL EXCLUSION

PROGRAM/ACTIVITY/PROJECT DATA:

Program/Activity Number: 621-0010

Country/Region: Tanzania

Program/Project Title: SO 10: Enhance Multisectoral Response to HIV/AIDS

Foreign Assistance Objective 3: Investing in People Program Area 3.1: Health

Program Element 3.1.1: HIV/AIDS

Prevention and HIV Testing

Sub element 3.1.1.2: Abstinence and Be Faithful Sub element 3.1.1.3: Medical Transmission/ Blood Safety Sub element 3.1.1.4: Medical Transmission/ Injection Safety Sub element 3.1.1.5: Condoms and Other Prevention Sub element 3.1.1.9: Counseling and Testing (CT)

Community Services: Care for People Living with HIV/AIDS (PLHA)

Sub element 3.1.1.6: Palliative Care: Basic Health Care and Support Sub element 3.1.1.8: Orphans and Vulnerable Children (OVC)

Clinical Services

Sub element 3.1.1.1: Preventing Mother-To- Child Transmission (PMTCT) Sub element 3.1.1.7: Palliative Care: TB /HIV Sub element 3.1.1.10: HIV/AIDS Treatment/ ARV Drugs Sub element 3.1.1.11: HIV/AIDS Treatment/ARV Services

Systems Strengthening Sub element 3.1.1.12: Laboratory Infrastructure Sub element 3.1.1.13: Other /Policy Analysis and System Strengthening Sub element 3.1.1.1.14: Host Country Strategic Information Capacity

Funding Begin: FY 2005_ Funding End: FY 2014; LOP Amount: $ 800.0 Million Sub- Activity

IEE Prepared By: David Kinyua USAID/EA, Regional Environmental Procedures and Policies Specialist and Mary Chale, USAID/Tanzania, HIV/AIDS Program Specialist Current Date: May 27, 2009

IEE Amendment (Y/N): Y If "yes", Filename 35Tanzania1_SO10_HIV_AIDS_PEPFAR & date of original IEE: 1-28-2005

ENVIRONMENTAL ACTION RECOMMENDED: (Place X where applicable) Categorical Exclusion: X Negative Determination: X .

Positive Determination: Deferral ___

ADDITIONAL ELEMENTS: (Place X where applicable)

CONDITIONS X PVO/NGO: X .

Other Relevant Environmental Compliance Documentation: This IEE references the following USAID environmental compliance documentation that is already in effect for ongoing activities under USAID/ Tanzania:

35Tanzania1_SO10_HIV_AIDS_PEPFAR Environmental Guidelines for Small Scale Activities in Africa (EGSSAA)

SUMMARY OF FINDINGS:

USAID / Tanzania HIV/ AIDS PEPFAR program under Strategic Objective No. 10 has four intermediate results: Prevention and HIV testing; Community Services-Care for PLHA; Clinical Services; and Systems Strengthening. The specific program activities however correspond to the four-teen sub-elements under HIV/AIDS as laid out in the Foreign Assistance framework grouped under the four Intermediate Results. The program currently has approximately 50, local and international, implementing partners. The program was covered by the IEE (35Tanzania1_SO10_HIV_AIDS_PEPFAR) of February March 2005, which reviewed the program activities during the design. The program has since increased in complexity and detail and required further environmental review to examine the additional program activities not previously and specifically reviewed at the design phase. The funding level for the PEPFAR program is likely to level-out at about $140 million per year and may not differ significantly from the level initially covered by the previous IEE.

This IEE, therefore, amends the existing one and specifically reviews all the program sub-elements (under the FA framework) being implemented by the USAID/Tanzania, HIV/AIDS team.

Environmental Determinations:

The following environmental determinations are recommended

1. A Categorical Exclusion from environmental examination is recommended for activities (See Sect.

3.6, Table 1 Activity Group 1) under:

All the activities under 3.1: Clinical Services except those involving supporting permaculture, renovation of facilities, provision of the ITNs and those involving health care treatment and test-ing involving blood, which are determined to be Negative Determinations;

All the activities under 3.2 Community Care for PLHA, except the activities involving permacul-ture, dealing and distribution of ITN and counseling and testing all of which are determined to be Negative Determinations;

All the activities under 3.3: Prevention and HIV Testing except those involving construction and renovation of facilities, provision of the ITNs and those involving testing involving blood, which have a different Threshold Determination in this IEE; and

All the activities under 3.4: Systems Strengthening except the activities involving construction and renovation of facilities which determination is provided for below:-based RH/FP f

Pursuant to the following 22CFR clauses:

a) 22 CFR 216.2(c) (2) (i), for activities involving education, training, technical assistance or training programs;

b) 22 CFR 216.2(c) (2) (iii), for activities involving analyses, studies, academic or research workshops and meetings;

c) 22 CFR 216.2(c) (2) (v), for activities involving document and information transfers; and

d) 22 CFR 216.2(c)(2)(viii), for programs involving nutrition, health care, or FP services except to the extent designed to include activities directly affecting the environment (such as construction of facilities, water supply systems, waste water treatment, etc.).

2. A Negative Determination (without Conditions) recommended pursuant to 22 CFR 216.3(a)

(2) (iii) for the following activities:

i) Backyard vegetable gardens deemed to incorporate adequate good agricultural practices:

Support permaculture gardening by for household food security, section 3.1.5: Adult care and treatment (Clinical Services) 3.2.2 Palliative care: Basic Health care and sup-port (Community Care for PLHA)

Conditions:

Application of appropriate guidelines and use of best practices in agriculture including applying the soil and water conservation technologies to protect land from degradation and reclaim land that has been degraded and using interventions that reduce habitat loss by increasing agricultural productivity and sustainability on already-farmed lands (using improved seed; using multiple cropping; using fertilizers, manures and irrigation and replacing old or inadequate irrigation systems; and rotating crops;). For further details on the agricultural best practices, see, http://www.enca-pafrica.org/EGSSAA/Word_English/agriculture.doc

i) Construction and renovation of facilities:

Renovation of Facilities as needed to improve patient flow and confidentiality, and expand ser-vice capacity, under Clinical services, section 3.1.3: Treatment and ARV services;

Implementing smaller scale construction projects by USG partners and MSD construction and renovation work to improve the storage and delivery capacity of their nine national and re-gional facilities under Systems Strengthening, section 3.4. 2 (Other /Policy Analysis and Sys-tems Strengthening)

Conditions:

Rehabilitation of existing facilities and construction of facilities in which the total surface area disturbed is less than 10,000 square feet shall be conducted following principles for environmentally sound construction, as provided in the Small Scale Construction chapter of the USAID Environmental Guidelines for Small-scale Activities in Africa, which can be found at: www.encapafrica.org.

All construction activities shall be conducted following principles for environmentally sound construc-tion, as provided in Chapter 3: Small Scale Construction of the USAID Environmental Guidelines for Small-scale Activities in Africa.

iii) Distribution of Long lasting Insecticide Treated Nets (LLITNs) under:

Providing bed-nets for exposed infants and HIV+ pregnant women under 3.1.1: Prevention of

Mother to Child Transmission (PMTCT) of Clinical Services component.

Collaborating with the President’s Malaria Initiative (PMI), National Malaria Control Pro-gram (NMCP), and GFATM regarding control of malaria for PLWHA and other vulnerable groups, including promoting the use of insecticide treated bed nets (ITNs) and supplying ITNs for the under five children and to ensure GFATM support reaches PLWHA under sec-tion 3.1.7 of the Clinical Services component

Funding bulk mosquito net and food purchases under section 3.2.1: Orphans and Vulnerable Children of the Community Care for PLHA

Providing bed-nets obtained through local distributors by using the national voucher scheme used by PMI or distribute bed nets through home-based care volunteers under section 3.2.2 Palliative Care: Basic Health Care and Support (Community Care for PLHA)

If the program includes support for the acquisition, distribution or marketing of LLITNs, the HIV/AIDS Teams and partner organizations will be required to use World Health Organization (WHO) approved brands of LLITNs and adhere to all relevant stipulations made in the USAID Africa Bureau Program-matic Environmental Assessment for Insecticide-Treated Materials in USAID Activities in Sub-Saharan

Africa (ITM PEA). If a need for net treatment or re-treatment arises, the Team will draft and gain approval for a “Pesticide Evaluation Report and Safer Use Action Plan” (PERSUAP) for the ITN program.

iv) Activities involving Health care, treatment and testing of blood:

3.1 Clinical Services:

3.1.1 PMCT

o Increasing coverage of PMTCT services; increasing uptake of PMTCT ARVs and more efficacious regimens; increasing child follow-up (including infant diagnosis and cotri-moxazole (CTX))Prevention, treatment, care and support services for adults and chil-dren;

o provider-initiated counseling and testing; WHO-tiered ARV approach; and TB screening

3.1.3 ARV Services

o Improving identification of pediatric cases and referrals for services; improving linkages with other programs to ensure and enhance a continuum of care (TB/HIV), Counseling and Testing (C&T), PMTCT, prevention services including a Prevention with Positive (PWP) initiative focusing on partner testing, disclosure, risk reduction, family planning, and treatment of sexually transmitted infections; improve the quality of treatment ser-vices at all levels; and scaling up the outlets for providing ART.

3.1.4 Palliative Care: TB/AIDS

o Supporting implementation of TB/HIV activities in both the TB clinic and CTC settings at regional and district levels and supporting the expansion of diagnostic testing and counseling for HIV in TB clinics.

3.1.5 Adult care and treatment

o Screening for cervical cancer among HIV-infected women

3.2 Community Care for PLHA:

3.2.2 Palliative Care: Basic Health Care and Support

o Piloting home counseling and testing, providing an opportunity to alter the policy to al-low for lay testers

3.3 Prevention and HIV Testing

3.3.3 Counseling and Testing

o Increasing access to Counseling and Testing (CT) services, particularly in high preva-lence areas and with most at risk populations. Specific areas of focus include develop-ment of services along transportation corridors and the use of mobile VCT centers for hard to reach high-risk groups.

o Expanding best practices, including continued roll-out of Provider- Initiated Testing and Counseling (PITC) o Strengthening CT programming at blood donation sites, increasing the identification of discordant couples, and screening for gender-based violence during CT sessions

3.3.4 Condoms and Other Prevention Activities

o Promoting Male Circumcision (MC) service package including the provision of HIV test-ing and counseling services to identify HIV-negative males eligible for circumcision, as recommended by WHO and UNAIDS;

o Providing treatment for Sexually Transmitted Infections (STIs) for HIV+ individuals o Addressing Injection Drug Use through community outreach, including voluntary HIV counseling and testing and promotion of safer sexual practices Conditions For all activities involving handling of blood, used bandages, sharps (including needles, syringes, scalpels, etc) and other medical wastes, the HIV/AIDS Team must work with its implementing partners to monitor (as detailed in section 4 of this IEE) the extent to which the medical facilities and operations involved have adequate procedures and capacities in place to properly handle, label, treat, store, transport and properly dispose of blood, sharps and other medical waste. If notified of inadequate procedures and capabilities through such monitoring, the Team will take appropriate mitigating action as outlined in ADS 204.3.4(b), assuring that adequate medical waste management procedures and capacities are put in place as soon as possible.

4. Pesticides: This IEE does not cover procurement, use, transport, storage or disposal of pesticides or other toxic materials, which would require an amended IEE, pursuant to 22 CFR 216.3(b), USAID’s Pesticide Procedures. Likewise, any activities implicating the testing and use of genetically-modified organisms (GMOs) or life-modified organisms (LMOs) shall be subject to review under the Agency’s Biosafety Procedures.

5. Monitoring, Evaluation and Reporting: As required by ADS 204.3.4, the HIV/ AIDS (SO 10) team must actively monitor ongoing activities for compliance with approved IEE recommendations, and modify or end activities that are not in compliance. If additional activities not described in this document are added to this program, then amended or new environmental documentation must be prepared. The SO team will also ensure that provisions of the IEE concerning mitigating measures and the conditions specified herein along with the requirement to monitor are incorporated in all contracts, cooperative agreements, grants and sub-grants.

The Tanzania HIV/AIDS PEPFAR Team will use an annual EMMR to ensure programmatic compliance with 22 CFR 216 and ADS 204.5.4 by documenting that the conditions specified in the SO 10 PEPFAR IEE have been met for all activities carried out under each bi-lateral award. The EMMR must be completed by each organization carrying out activities under a USAID/Tanzania SO 10 bi-lateral award.

The EMMRs will be reviewed and approved by the CTO and the Mission Environmental Officer.

The EMMR consists of 3 parts:

1. The Environmental Verification Form

2. The Mitigation Plan for specific environmental threats carried out by the implementer

3. The Reporting Form

The EMMR Environmental Verification Form Because of the integrated nature of the USAID/Tanzania PEPFAR portfolio, a single bi-lateral award (along with any sub-awards) often contains activities having different conditions required for prevention or mitigation of environmental impact. This form indicates the categories of activities carried out by implementing partners (or their sub-awardees).

The EMMR Mitigation Plan The Mitigation Plan describes specific actions that will be undertaken under each category of activity when screening reveals potential environmental threats as outlined in Section 3 of this IEE. In these cases, mitigation will be undertaken as described in Section 5 of this IEE. It also identifies the person responsible for monitoring compliance with mitigation and the indicator, method and frequency of monitoring.

The EMMR Reporting Form This form reports on the results of applying the mitigation measures described in the Mitigation Plan and identifies outstanding issues with respect to required conditions. In some cases, digital photos will be the best way to document mitigation and should be included in the report.

APPROVAL OF THE RECOMMENDED ENVIRONMENTAL ACTION:

CLEARANCE:

Mission Director: ____________/cleared/________________ Date: 6/10/2009 Robert F. Cunnane

CONCURRENCE:

Bureau Environmental Officer USAID/AFR BEO: _____________________________ Date: ________ Brian Hirsch Approved:

Disapproved:

Filename: Tanzania_FY08_FO3_HIV-AIDS_IEE_Amendment1

CLEARANCE:

ADDITIONAL CLEARANCES: (Add as appropriate; type name under signature line)

Mission Environmental Officer USAID/Tanzania: /cleared/ ______ Date: 6/10/2009 Gilbert Kajuna

HIV/AIDS (SO 10) Team Leader: _/cleared/__ ______ Date: 6/10/2009 (Acting ) Laura Skolnik

Regional Environmental Officer (USAID/EA): /cleared/ ______ Date: _6/30/2009_ Walter Knausenberger

INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ACTIVITY/PROJECT DATA:

Program/Activity Number: 621-0010

Country/Region: Tanzania

Program/Project Title: SO 10: Enhanced Multisectoral Response to HIV/AIDS.

Foreign Assistance Objective 3: Investing in People Program Area 3.1: Health

Program Element 3.1.1: HIV/AIDS

Prevention and HIV Testing

Sub element 3.1.1.2: Abstinence and Be Faithful Sub element 3.1.1.3: Medical Transmission/ Blood Safety Sub element 3.1.1.4: Medical Transmission/ Injection Safety Sub element 3.1.1.5: Condoms and Other Prevention Sub element 3.1.1.9: Counseling and Testing (CT)

Community Services: Care for People Living with HIV/AIDS (PLHA)

Sub element 3.1.1.6: Palliative Care: Basic Health Care and Support Sub element 3.1.1.8: Orphans and Vulnerable Children (OVC)

Clinical Services

Sub element 3.1.1.1: Preventing Mother-To- Child Transmission (PMTCT) Sub element 3.1.1.7: Palliative Care: TB /HIV Sub element 3.1.1.10: HIV/AIDS Treatment/ ARV Drugs Sub element 3.1.1.11: HIV/AIDS Treatment/ARV Services

Systems Strengthening Sub element 3.1.1.12: Laboratory Infrastructure Sub element 3.1.1.13: Other /Policy Analysis and System Strengthening Sub element 3.1.1.14: Host Country Strategic Information Capacity

Funding Begin: FY 2005_ Funding End: FY 2014; LOP Amount: $ 800.0 Million Sub- Activity

1. PURPOSE AND SCOPE OF THIS INITIAL ENVIRONMENTAL EXAMINATION (IEE)

USAID / Tanzania HIV/ AIDS PEPFAR program under Strategic Objective 10 has four intermediate results: Prevention and HIV testing; Community Services-Care for PLHA; Clinical Service; and Systems Strengthening. The specific program activities are the four-teen sub-elements under HIV/AIDS (Foreign Assistance Framework) grouped under the four Intermediate Results. The program currently has forty seven, local and international, implementing partners. The program was covered by the IEE (35Tanzania1_SO10_HIV_AIDS_PEPFAR) of February March 2005 which reviewed the program activities during the design. The program has since increased in complexity and detail and required further environmental review to examine the additional program activities not previously and specifically reviewed at the design phase. The funding level for the PEPFAR HIV/AIDS program is likely to level out at about $140 million per year and may not significantly differ from the level initially covered by the previous IEE.

This IEE therefore amends the existing IEE and specifically reviews all the program sub-elements (under the FA framework) being implemented by the USAID/Tanzania, HIV/AIDS team.

The purpose of this IEE is to provide threshold determinations for the SO in accordance with the requirements of Regulation 22 CFR 216 (Reg. 16), ADS 204.5.4 and ADS 303. This is meant to achieve environmentally-sound activity designs, and also to allow for future amendments of the IEE as new activities are added or existing ones are extended or cancelled. The SOs’ team members and activity implementing partners are responsible for the implementation of recommended environmental mitigation and monitoring measures and for ensuring that the activities remain as Categorical Exclusions, and within the bounds of Negative Determination with Conditions.

2.0 SUMMARY OF COUNTRY ENVIRONMENTAL INFORMATION

Background information provided in the original IEE (35Tanzania1_SO10_HIV_AIDS_PEPFAR) of February March 2005 has been amended by this IEE. Note that when the term “USG” is utilized the content refers to the work of all 5 PEPFAR agencies.

3.0 USAID/TANZANIA PEPFAR PROGRAM DESCRIPTION

The HIV/AIDS program in Tanzania has several major components: Clinical Services; Prevention and HIV testing; Community Care for People Living with HIV/AIDS (PLHA); and Systems Strengthening.

The program currently has approximately 50 implementing partners working across the four areas. The FY09 budget is about $140 million and is likely to stay close to that level every year for the next five years. For the purpose of this environmental examination, the activities within each program area are summarized below, focusing more on what the program is planning on implementing, while leaving out program rationale and background information.

3.1 Clinical Services

The Clinical Services in USAID/Tanzania covers Prevention of Mother-to-Child Transmission (PMTCT), AIDS treatment and ARV drugs, Pediatric AIDS and treatment of patients co-infected with HIV and Tuberculosis. These specific sub-elements are briefly described below.

3.1.1 Prevention of Mother-to-Child Transmission (PMTCT)

The Government of Tanzania (GOT) has expanded PMTCT services from five sites in FY 2004 to 659 sites (323 dispensaries, 191 health centers, 137 hospitals, eight refugee camps) in FY 2007, of which 502 (76%) are directly supported by USG.

In order to further strengthen the program, significant improvements are needed: increased access to services; increased utilization of counseling and testing services at labour and delivery wards; increased uptake of ARV prophylaxis; strengthened postnatal follow up and infant feeding support; increased provision of basic preventive care to mothers and infants; and strengthened linkages to care and ART. An additional concern is the weak referral systems between PMTCT and ARV services. Between October 2006 and March 2007, only 2.7% of new ART patients were pregnant women. To expand comprehensive PMTCT services rapidly, and align better with the USG 5-Year Strategy, USG will support the Ministry of Health and Social Welfare (MOHSW) in the regionalization of PMTCT services. Under this plan, six USG ART partners will lead the scale-up and support of PMTCT services within their assigned 20 geographic regions. ART partners are expected to work with regional and district authorities to coordinate and strengthen implementation of PMTCT sites and linkages between PMTCT and adult and pediatric care and ART, including early infant diagnosis. By March 2008, MOHSW will have fully shifted from a role of PMTCT implementation to a role of national program coordination and management. Regionaliza-tion of PMTCT will follow the success of ART regionalization, address staffing constraints at MOHSW, strengthen linkages between ART and PMTCT services, and support an integrated approach to care and treatment.

The following are FY 2009 priorities:

increase coverage of PMTCT services;

increase uptake of PMTCT ARVs and more efficacious regimens;

increase child follow-up (including infant diagnosis and cotrimoxazole (CTX); and strengthen PMTCT M&E. USG including USAID) will support partners to expand PMTCT to 1,000 sites by the end of FY 2008 and 1,270 sites by the end of FY 2009.

In using a district network approach, implementing partners will provide technical assis-tance and mentoring to district health authorities rather than solely providing facility-based support.

USG will also work with care and ART partners to implement:

o provider-initiated counseling and testing;

o WHO-tiered ARV approach;

o support for exclusive breastfeeding with early weaning;

o growth monitoring;

o nutritional supplementation;

o CTX prophylaxis for HIV-exposed infants;

o infant diagnosis by dried blood spot (DBS) DNA PCR or other methods;

o TB screening;

o family planning for HIV+ women; and o bed-nets for exposed infants and HIV+ pregnant women.

People Living with HIV/AIDS (PLWHA) groups will assist with referrals and follow-up, and invitation letters will be used as one way to increase male involvement

USG will provide technical assistance to ensure availability of essential drugs, test-kits, and supplies for PMTCT and to strengthen the Integrated Logistic System (ILS).

Traditional Birth Attendants (TBAs) and local communities will be sensitized to support HIV+ mothers to access PMTCT services, refer them to deliver in health facilities, and assist with fol-low-up.

Radio will be used as an additional community sensitization media.

To ensure effective PMTCT-ART linkages, quality improvement teams will be formed at sites to develop facility-based referral mechanisms; the team will also work with smaller PMTCT fa-cilties and surrounding hospitals to maximize referrals upward to ART clinics.

3.1.2 Treatment and Antiretroviral (ARV) Drugs

In Tanzania, first-line ARV drugs are procured by the Ministry of Health and Social Welfare (MOHSW) with Global Fund or other donor funds, and the US Government (USG) funds alternative first line drugs, second-line and pediatric formulations. The USG supports the strengthening of the national system, the quantification for all drugs and related commodities, and funds the purchase of commodities and a limited number of drugs when requested by the MOHSW.

To bolster the Medical Stores Department (MSD) distribution system, the USG will provide assistance to the MSD to strengthen its management and reporting systems. The USG has already provided support and technical assistance to scale up the Integrated Logistics System (ILS) for essential drugs and commodities including PMTCT, ART, and home-based care. The ILS serves as the backbone for data management at the MSD and was recently assessed and compared favorably to the pre-packed “push” reporting system that is used in other districts. The USG team plans to expand the ILS out to all regions in FY 2009.

With the resources available, the USG will:

Support the GoT in analyzing facility-level data and provide technical assistance on quantifica-tion and procurement.

The USG will continue to support regional and zonal teams that work at facilities on monitoring stock, quantifying drug requirements, and providing on-the-job training on data management and reporting through the ILS.

USG will procure ARVs for 1st line alternatives, second line adult and pediatric regimens through a single partner which buys Food and Drug Administration (US FDA) approved or tenta-tively approved ARVs that are registered in Tanzania and are selected based on the national standard treatment guidelines.

This program will be involved in forecasting the need for the ARVs, securing them up to the medical stores department, freight forwarding and providing technical leadership and capacity building in logistics management functions, including forecasting, procurement planning, and in-ventory management.

3.1.3 Treatment and Antiretroviral (ARV) Services

An estimated 400,000 Tanzanians have advanced HIV infection and would benefit from HIV treatment.

The Government of Tanzania (GoT) has made significant progress in expanding access to antiretroviral therapy (ART) with the number of service outlets providing ART increasing from 32 in 2004 to over 200 in 2007. At the end of March 2007, 71,584 patients were currently on ART, compared with approximately 30,000 one year earlier. Logistical systems for the distribution of medications and ART monitoring systems were strengthened. Availability of drugs has improved and the “pull” system (where ART sites order drugs based on need) has been fully implemented. The GOT has ambitious plans to expand some ART services to a 500 health centers for a total of over 700 ART service outlets by the end of 2008.

However, Tanzania continues to face human capacity shortages, limited laboratory capacity, fragile procurement systems, and weak referral systems; all of which have been compounded by technical and policy challenges.

USG will support:

Implementing recruitment and retention measures at the district level to complement the emer-gency hiring plan, which is supported by Global Fund monies provided to the Mkapa Founda-tion.. Preceptors will be identified to provide mainly clinical skills in support of the roll out of ARV services.

Providing technical assistance to build the capacity of the regional and district authorities in both management and provision of supportive supervision of treatment services.

Ensuring that all facilities receive agreed-upon standards for a minimal level of support from clinical services partners. These will include o training of a primary and secondary team of ART clinic staff, o provision and participation in regular supportive supervision site visits, o active promotion of provider-initiated HIV testing, o support for prevention with positives (PWP) programs, including partner testing, disclo-sure, risk reduction, family planning, and treatment of sexually transmitted infections) o post-exposure prophylaxis, o advocacy for inclusion of ART services within the regional and district budgets, o strengthening of systems for case reporting and record keeping as per national standards, o establishment of clinical mentoring by distance communication (mobile phone), and de-velopment/strengthening of referral systems and linkages to community care programs.

Renovating facilities to improve patient flow, expand patient service capacity, and ensure confi-dentiality, and provide equipment and supplies not provided from the GoT or Medical Stores De-partment. This will be done in coordination with the GoT to ensure essential equipment mainte-nance and support through the national system.

Provision of:

o improved linkages with other programs to ensure and enhance a continuum of care (TB/HIV, C&T, PMTCT, prevention services.

o improved quality of HIV/AIDS-related clinical services at all levels.

Identifying HIV-exposed infants and initiation of HIV care; raising health care worker awareness and clinical skills in pediatric care, promotion of provider-initiated testing among children, and routinely recording mothers’ HIV-status in the child health card.

Help enrol more than 200,000 HIV-positive patients on ART; and train more than 9,000 health care workers by the end of FY 2009.

3.1.4 Palliative Care: Tuberculosis (TB) /HIV

The Tanzania Health Sector Strategy on HIV/AIDS identifies Tuberculosis (TB) as the leading cause of death among people living with HIV/AIDS (PLWHA).

USG supported the hiring of 31 TB/HIV Coordinators to perform supportive supervision on TB/HIV co-management activities, the conduct of on-the-job training at points of service; and follow up of referrals between CTC and TB clinics. A standard TB screening tool has been developed and disseminated to all ART partners in the country. In addition, following the success of the pilot introduction of ART in TB clinics, NTLP and NACP are expanding this approach to 10 more TB clinics in an attempt to address the low up–take of referrals between TB clinics and CTC.

A major focus in FY 2009 in TB and TB/HIV services will be improving overall capabilities.

Strengthening smear microscopy in all diagnostic centers by procuring Light Emitted Diode (LED) microscopy units with at least on unit to be placed in each district; introducing a new, sensitive diagnostic technique with less turn around time by placing Mycobacterium growth in-dicator tube (MGIT) equipment at zonal referral labs

Developing an efficient specimen management and transportation system for the peripheral diagnostic centers to access the high volume MGIT.

Strengthening the existing smear microscopy quality assurance activities at all levels of service delivery.

Supporting the implementation of TB/HIV activities in both the TB clinic and CTC settings at regional and district levels.

Strengthening systems to screen all HIV patients for TB and improving monitoring systems to track their referrals to TB clinics, Working with the NTLP and NACP to ensure that the newly-modified TB monitoring tools are introduced at all USG ART sites.

Supporting the expansion of diagnostic testing and counseling for HIV in 600 TB clinics in 93 districts.

3.1.5 Adult Care and Treatment

USG programs are designed in support of the National Multi-sectoral Strategic Framework (NMSF), the Health Sector Strategy and the Emergency Plan Five-year strategy. At the time of the initiation of the Emergency Plan in September 2004, only about 1,500 – 2,000 of the estimated 440,000 people in need were receiving Anti-retroviral therapy (ART).

One of the successes of the Tanzanian Care and Treatment Program stems from a regionalization approached initiated by the Ministry of Health and Social Welfare (MOHSW) through the National AIDS Control Program (NACP) in FY 2005.

FY 2009 funds will support:

Rolling out facility-based nutritional assessments of PLWHA in care and treatment programs to identify those eligible for therapeutic supplementary feeding support.

Initiating a Food by Prescription (FBP) program to eight treatment facilities, with the lessons from this pilot helping to inform a scale up of the program in FY 2009.

Continuing to provide nutrition education and support permaculture gardening, an easy and effective method for families to provide for basic nutritional needs.

Continuing to link with Government of Tanzania (GoT) through relevant ministries, other devel-opmental partners as well as the implementing partners in addressing household food security.

Supporting a number of efforts to build capacity, strengthen systems, and address barriers faced by the program, including policy development, guideline development, adaptation of training materials, program planning and implementation, supportive supervision, and monitoring and evaluation.

Strengthening Local Government Authorities’ (particularly district councils) leadership and management approaches to assure greater accountability and sustainability.

Screening for cervical cancer among HIV-infected women.

Coordinating with the President’s Malaria Initiative (PMI), National Malaria Control Program

(NMCP), and GFATM regarding control of malaria for PLWHA and other vulnerable groups.

USG and partners will to ensure that policies and guidelines are consistent and that malaria pre-vention and treatment guidelines are implemented in HIV care settings, and health promotion messages are followed up by the community-based care providers including promoting the use of insecticide treated bed nets (ITNs). In addition, USG will be leveraging the large program for universal coverage for ITNs expected to be funded through GFATM to ensure the support reaches

PLWHA.

Procuring water purification tablets and water storage containers for distribution through a social marketing program.

Developing a comprehensive Prevention with Positives program, both in facilities and through the community

Improving the linkages between care and support services, particularly enhancing the roles of community care providers in TB screening and referrals, pain management, screening for oppor-tunistic infections and assisting patients prescription refills. An activity to develop and supply informational brochures and job aids to assist HBC providers will be expanded in FY 2009.

3.2 Community Care for PLHA

3.2.1 Orphans and Vulnerable Children

In Tanzania, about 2.5 million children under the age of 18 (over 10%) are considered orphans and/or vulnerable children (OVC). About 40% were orphaned due to AIDS-related diseases, and many are vulnerable due to a chronically ill parent who is unable to properly care for them. With USG support, the program has served 268,125 children

In FY 2009, the USG will focus primarily on improving the coverage and quality of services provided by USG-funded partners.

Strengthen the GOT Department of Social Welfare (DSW) at the Ministry of Health and Social Welfare. Through overall national system strengthening, including the secondment of a capacity building officer, a strategic planning officer, and a DMS specialist.

Will support an assessment to determine gaps between current OVC partner practices and the expected service to be provided according to the standards set for each service area.

Will support the development of a simplified version of national caretaking skills standard pack-age for OVC and the integration of an anti-stigma tool for children.

Will strengthen professional skills of the caregivers and communities to meet the needs of OVC.

The USG will continue strengthen the Tanzanian Institute of Social Work’s pre- and in-service social work training and national training for para-professional social workers.

Directly support the development of short- and long-term hiring and training plans in addition to a performance-based evaluation of social workers.

Continue to support the management of the OVC IPG group and facilitate the functioning of the

National Steering Committee and the National Technical Advisory Committee. At the district level, the USG will support capacity building of local government authorities, sub-grantee non-government organizations (NGOs), community-based organizations (CBOs), and faith-based or-ganizations (FBOs).

Wraparounds to improve food security and nutrition services for OVC will be piloted in the USG-supported districts after completion of the OVC food security assessment focusing on effective-ness of food and nutrition interventions.

Strengthen households, the MVCC, and child-headed households through provision of agro-business and entrepreneurial skills in addition to small loans. The Ministry of Agriculture will contribute to policy development of OVC household food security and will expedite and ensure supportive supervision of agriculture extension workers.

Fund bulk mosquito net and food purchases.

The USG will also encourage strengthening and expansion of local communities’ social networks that support OVC, elder caregivers and affected households to coordinate quality care.

The USG will ensure linkages with palliative care and antiretroviral treatment (ART) programs, OVC, other child-related services, and malaria prevention and treatment.

USG partners will work to identify HIV-positive OVC, linking them to HIV care and treatment services and community pediatric care. Additional emphasis will be placed on anti-stigma train-ing and communication activities that can dually strengthen the coping abilities of MVCC, fami-lies, and communities.

Support development of national guidelines, finalization of the Children’s Act to ensure protec-tion and legal aid to OVC and caregivers at all levels, and the initiation of a child-friendly police program, which will impart basic knowledge on “interactive child service” in police work.

Support a monitoring framework to track compliance with service standards and related partner performance improvements and changes in child wellbeing.

support the ongoing process of integrating the para social workers cadre into social welfare services work scheme as Welfare Assistants at ward levels, in order to ensure community access to welfare services and other capacity development initiaves like learning districts which will in-volve exchange visits, electronic communications, and IPG forums at all levels.

Engagement with the private sector to improve their economic strengthening activities and ensure they are market-driven, as well as leverage opportunities to develop skills on small business de-velopment, financial management and resource mobilization.

Assess technical inputs to assess best practices in improving food and nutrition security in which will lead to meeting the food and nutritional needs of households caring for OVC. Such initia-tives may include public-private partnerships that engage the agro-business sector and the exten-sion workers of the Ministry of Agriculture to address the food and nutrition security needs of households caring for OVC.

Tanzania has an estimated 2.4 million people living with HIV/AIDS (PLWHA). While about half of adult patients admissions are due to HIV related illnesses, only a small fraction of PLWHA receive palliative care.

Partners serving PLWHA under the Emergency Plan strive to provide a basic package of care services.

This includes clinical/medical care (basic pain and symptom management, nursing care, opportunistic infection prevention and treatment, malaria prevention and referral for treatment, monitoring for treatment side effects and adherence, referrals for TB screening and treatment, and nutritional counseling). Other services include spiritual care (such as participation in support groups and visitation by spiritual mentors), psychological care (support for disclosure and future life planning), social support (linking with food security interventions and income-generating activities), prevention services (such as prevention or behavioral counseling), distribution of condoms, and referral for family planning as appropriate. Safe water, hygiene instruction, and Insecticide Treated Nets (ITNs) have also recently been initiated as part of the package.

The focus for FY 2009 funding includes:

Continuing expansion of the “standard” service package and geographic coverage; strengthened linkages between HIV/AIDS care and treatment clinics and community-based services; strength-ened monitoring capabilities, and demand generation through radio spots.

Expanding pilots of home-based counseling and testing, providing an opportunity to alter the policy to allow for lay testers.

Putting greater emphasis on strengthening the coordination and normative role of the NACP, assist in updating guidelines for palliative care beyond HBC, assist with key policy issues, and achieve cost efficiencies through centrally planned, approved, and printed IEC materials.

Strengthening linkages with TB services, the President’s Malaria Initiative (PMI), reproductive health, and child survival.

Expanding the successful permaculture gardening/nutritional education program linking with other USG partners, and complementing their service package.

Developing a national monitoring system that will be rolled out to all regions Enhancing the ability of HBC providers to monitor patients and link to treatment facilities for referrals and back-up support by piloting in remote areas through a solar power public private partnership and the use of electronic devices.

Completing an assessment of best practices to provide targeted nutritional support and identify methods and products for getting adequate nutrition to PLWHA.

Developing pediatric-focused palliative care services to complement the additional case finding underway with USG treatment partners.

Inform national policy and be actively involved in the planning for and implementation of a national monitoring system.

Expand the present HBC guidelines to a broader set of services for palliative care.

Work to reduce stigma and discrimination within the communities through utilizing existing peer education and community sensitization tools.

Seek participation of PLWHA in designing and administering care services, and linking PLWHA with support groups that work with community leaders to reduce stigma.

Build capacity at the local level to ensure that local care and treatment centers and non-governmental organizations (NGOs) providing home-based care establish a strong two-way re-ferral system and greater accountability.

Ensure that the database is rolled out and maintained locally, to facilitate the use of data for management, decision-making, and coordination purposes at all levels.

Provide support for improvements to the supply chain system for essential medicines and prod-ucts to ensure availability of cotrimoxazole, test kits, and HBC kits.

Procure water purification tablets for distribution and provide bed nets.

3.3 Prevention of and HIV Testing

USG will emphasize program quality and impact, scaling-up efforts in high-risk locations and with high-risk populations through evidence-based interventions. Prevention activities will be incorporated into all

PEPFAR-funded program areas, to maximize opportunities and reach.

The portfolio will focus on the geographic areas, populations, and behaviors which data suggests are driving the Tanzanian epidemic, while balancing the need to ensure broad geographic coverage of prevention programming. To address the evolving Tanzanian context, the portfolio will build on gains achieved in FY08 through implementation of programming efforts outlined below.

USG will increase its focus on “be faithful” (“B”) and multiple, concurrent partnership (MCP) programming for adults, sexually active youth, and couples through targeted programs and complex behavior change messaging, to continue translating HIV awareness into safer practices. Efforts will include:

programming to reduce MCP;

intense behavior change campaigns via mass media (radio, TV, print) and inter-personal commu-nication (community mobilization, individual risk reduction counseling);

messaging around transmission dynamics, window period, and early/acute infection;

emphasis on prevention of alcohol abuse; and expansion of male circumcision (MC) and gender-based violence (GBV) programming. Prevention with Positives (PWP) programs will target HIV-positive individuals and sero-discordant couples with risk reduction messages; activities will stress the importance of counseling and testing (CT), especially couples CT and disclosure.

For most at-risk populations, USG will provide a comprehensive package of risk reduction services which includes peer outreach and education (e.g., correct and consistent condom use, sexual health, empowerment), mass media, condom distribution, CT, STI referrals and treatment (as appropriate), and linkages with care and treatment. These services will be targeted for the needs of high-risk groups, including sex workers, fishermen, truckers and uniformed service personnel. Efforts will also focus on addressing sexual risk-taking among IDUs and their partners, including in Zanzibar, to address the high rates of transmission among IDU populations and prevent bridging into the general population. Condom promotion efforts will be targeted to high-risk venues and populations, includ-ing discordant couples and HIV-positive individuals through expanded PWP programming.

USG will focus on addressing the low age of sexual debut, preparing youth to transition to healthier sexual behaviors, and reinforce the portfolio’s emphasis on key risk behaviors and translating aware-ness into safer practices.

The portfolio will continue to harmonize activities, including coordination of youth prevention programs; collaboration among main implementing partners on alcohol and drug abuse, “air war” and “ground war” plans, and sharing of lessons learned; and linkages among gender norms activities.

3.3.1 Abstinence and Be Faithful Programs

Key prevention priorities for PEPFAR’s AB program are to: 1) empower young people with the knowledge and skills to dialogue about sexuality, adopt attitudes and practices that protect them against HIV-infection and improve access to youth friendly services; 2) reduce risk of infection among those most vulnerable due to socio-cultural factors, gender inequality and sexual abuse; and 3) increase the involvement of public and private sector enterprises and informal sector operators in the development and implementation of comprehensive workplace interventions with special attention for mobile and migrant workers; and 4) address risk behaviors which place women and men at increased HIV risk, including engaging in multiple, concurrent partnerships and transactional sex. The USG priorities listed above fall within the Government of Tanzania (GOT)’s Strategic Framework.

The USG AB portfolio approaches include:

Focus on addressing the low age of sexual debut, preparing youth to transition to healthier sexual behaviors, and reinforce the portfolio’s emphasis on key risk behaviors and translating awareness into safer practices. Programs targeting decision-makers, power-holders and gatekeepers will complement efforts with youth.

Bringing to scale programs targeting adults with strengthened ‘B’ activities addressing socio-cultural and gender norms that promote high risk behaviors such as multiple concurrent partners, trans-generational sex, gender-based violence, and increased sexual risk taking related to alcohol use/abuse as well as other substance abuse such as IDU.

PWP programs will target HIV-positive individuals and sero-discordant couples with risk reduction messages; activities will stress the importance of CT, especially couples CT and disclosure.

Efforts to effect normative social and cultural change, addressing gender and social norms that underlie key behavioral drivers (MCP, cross-generational sex, transactional sex) and/or hinder protec-tive behavior change; and safe environments for vulnerable girls and women including GBV preven-tion. A critical focus will be work with community leaders, men, and the education sector to trans-form norms that promote predatory sexual behavior, including sexual violence as well as work with women and girls around skills development (e.g., condom negotiation, avoidance of trans-generational sex).

Wrap-around programs will ensure that particularly vulnerable groups have access to livelihoods and training.

The 2008 USG AB program includes a broad portfolio of implementing partners, spanning public and private sectors and coordinating closely with national, regional and local governments.

3.3.3 Counseling and Testing

HIV counseling and testing (CT) is recognized as the main entry for HIV/AIDS treatment, care, and support services. As a result, the Government of Tanzania (GOT) is committed to increasing access to CT services. GOT introduced new testing modalities in FY 2007 with technical assistance from the USG.

Most notable among these is Provider - Initiated Testing and Counseling (PITC). The roll-out of this strategy will significantly increase access to testing in clinical settings. Home-based testing is another CT method that was endorsed by GOT. Finally, another area of progress within CT has been GOT’s rollout of new M&E tools, which capture data at both community and clinical CT settings. The revised tools developed with technical assistance from USG staff and partner, will provide more complete and accurate CT data.

In FY 2008 both the GOT and the USG will maintain an emphasis on demand creation while simultane-ously expanding access to CT services to the underserved and most at risk. A priority will also be on ensuring adequate testing supplies and improving service delivery in the coming year. The activities will include:

Support to a radio communication partner. The focus will continue to be on “testing literacy”, location information, as well as addressing stigma and…